News
Q3 2025 Provider Newsletter
Date: 08/28/25
NEW: Highlighting Wellcare
We are excited to announce that we are beginning to spotlight Wellcare news in our Tennessee Newsletter. You can find more information pertaining to Wellcare midway through the newsletter highlighted in teal.
Suicide Prevention Awareness Month
September begins Suicide Prevention Awareness Month, which is a crucial time dedicated to raising awareness about mental health struggles and suicide prevention. The nationwide observance strives to raise awareness about the stigmatized topic, identify ways to prevent suicide, and to remember all of the lives that have been lost and affected by suicide. As part of the National campaign: National Suicide Prevention Week is observed Sunday, September 7, 2025 - Saturday, September 13, 2025 with World Suicide Prevention Day being recognized on Wednesday, September 10, 2025.
Our team wants to offer support by sharing several resources below.
- 988 Suicide & Crisis Lifeline: a 3-digit number for connecting with crisis counselors 24/7.
- Tennessee Statewide Crisis Line: 1-855-274-7471 or text “TN” to 741741, which offers free and confidential help from trained mental health professionals 24/7.
- TN Department of Mental Health and Substance Abuse Services: https://www.tn.gov/behavioral-health/crisis.html.
- TN Suicide Prevention Network: https://www.tspn.org/.
If you or someone you know is in immediate danger or experiencing a mental health emergency, call 988 or call 911.
System Upgrade and Outage Scheduled for Oct. 10, 2025
As part of ongoing system maintenance, Ambetter of Tennessee’s authorization system will be upgraded, requiring a scheduled system outage Friday, Oct. 10 at 10 p.m. CT through Monday, Oct. 13 at 7 a.m. CT.
During this scheduled outage, we will be unable to receive authorization requests except as noted below. Please resume submissions of your authorization requests on Monday, Oct. 13, 2025.
How to Plan for the Outage:
- Plan accordingly and submit any urgent or time-sensitive authorization requests prior to the scheduled downtime.
- For urgent authorization requests during the outage, call 1-833-837-0188. Of note, this number will only be active during this downtime.
- Beginning Monday, Oct. 13 at 7 a.m. CT., providers may submit authorization requests as usual.
If you have any questions, please contact your Provider Engagement representative.
New Provider Updates Tool
Ambetter of Tennessee is committed to offering our providers the best tools possible to support their administrative needs. Contracted providers can utilize our new online Provider Demographic Updates form to submit demographic updates, including office hour changes, phone/fax number updates, add/term a service location, practitioner terminations and more. The form can be found on our Ambetter of Tennessee Provider Resources webpage under Credentialing and Demographic Updates. Please be aware that some updates require the submission of corresponding documentation.
Providing Quality Care
Ambetter of Tennessee values your ability to serve our members. The health plan encourages our providers to engage in Cultural Humility trainings and education to promote positive interaction with diverse cultures. Cultural Humility and other quality care resources can be found on our website.
Ambetter Health Solutions
Ambetter of Tennessee is rolling out a new network effective January 1, 2026. The new network will be Ambetter Health Solutions which will be under our standard Marketplace-Exchange product. The Ambetter Health Solutions network will exclusively service the Individual Contribution Health Reimbursement Arrangement (ICHRA) market, an employer-sponsored approach to access health insurance options for employees through Marketplace products.
With employer-sponsored health plans continuing to become more cost prohibitive, ICHRAs can be an option to make costs more predictable while offering more plan options for employees to choose from. ICHRAs can make coverage possible for employers that have traditionally not offered health insurance for their employees.
The ICHRA market is expanding at a 30% annual rate and Ambetter Health Solutions will provide coverage designs geared toward the specific needs of this growing population.
How an ICHRA Works:
- Employers Select a Benefits Platform—Benefits platforms act as an administrator, coordinating transactions, providing decision support to employees, and serving as a place to enroll.
- Employers Define Their Contribution—Employers set an overall budget and the pre-tax contribution for healthcare coverage.
- Employees Shop Marketplace Plans & Enroll—Employees shop plans based on their own unique needs and enroll through your chosen benefits platform.
- Employees Get Reimbursed—Employees are reimbursed for health coverage based on employer-defined contributions.
ICHRAs Will Attract Employers Who:
- Have unaffordable coverage or unsustainable premium increases.
- Have a diverse workforce with different healthcare needs.
- Want to offer more choice to attract talent.
- Have workers in multiple states without a single-carrier solution.
- No longer wish to manage health risks amongst their workforce.
Under Ambetter Health Solutions plans, providers will be able to track these members through a unique member card. Ambetter Health Solutions members will experience the wide array of coverage and perks available to current Ambetter members such as the Ambetter Health App, Pharmacy Program, Virtual 24/7 Care, and Care Management Services.
Please Note: As a current Ambetter provider, there is nothing you need to do to be part of this network and see new Ambetter Health Solutions members after January 1, 2026.
Quality Improvement
Mammogram Facility Incentive Program
With Breast Cancer Awareness Month just around the corner beginning in October, we wanted to take a moment to acknowledge all who have been affected by the disease and its effects. Breast Cancer Awareness Month is a time annually devoted to a number of campaigns and programs designed to support those who have been diagnosed with breast cancer, educate people about breast cancer risk factors, encourage regular breast cancer screenings, and raise money for breast cancer research.
As a part of our commitment to Quality care, we have implemented the Mammogram Facility Incentive Program (MFIP). Our Ambetter Mammogram Incentive Program recognizes facilities like yours that deliver and appropriately document mammography services to members. The measure period for the Ambetter Mammogram Facility Incentive Program is from June 16, 2025 to December 31, 2025.
The program leverages your existing workflow as follows:
- Schedule and conduct patient mammograms.
- Submit a claim/an encounter containing all appropriate diagnostic and procedure codes, and document in the member’s medical record.
Payment will occur Q2 2026. All claims/encounters must be submitted by Jan. 31, 2026. They will be used in calculating the payment. Please note that only screenings completed for assigned members June 16, 2025 to December 31, 2025 are eligible.
We’re excited to share the current list of radiology facilities participating in our program:
- Parkridge Medical Center
- Parkridge East Hospital
- Tennova Healthcare—Clarksville
- Tennova Healthcare—North Knoxville Medical Center
- Sumner Regional Medical Center
- Abercrombie Radiological Consult
- St. Francis
We appreciate the commitment of these facilities in helping us drive better outcomes and close care gaps for our members!
Risk Adjustment
Risk Adjustment Data Validation (RADV)
We’ve officially launched our annual RADV Audit Chart Chase Project, and we need your assistance in responding to a Department of Health & Human Services (HHS) mandated audit. The HHS initiates and oversees audits of health plans, particularly those participating in Medicare Advantage (MA) and subject to risk adjustment under the Affordable Care Act (ACA). Ambetter of Tennessee and Wellcare is included in the audit and we, along with our contracted providers, must fully comply. Please prioritize the medical record requests coming from the vendor Optum.
Risk Adjustment(Continuity of Care/CoC)
Ambetter of Tennessee and Wellcare are committed to supporting your efforts of providing the highest quality care to our members. As a result, we have launched our Continuity of Care (CoC) program for 2025. This initiative incorporates Appointment Agendas, HEDIS measures, and pharmacy metrics into one comprehensive view. The CoC program is designed to support your outreach to members for annual visits and condition management, which will help us better identify members who are eligible for case management. For more information on the CoC program and Provider Incentive Payout Bonus, please refer to your provider portal or your health plan representative.
Risk Adjustment (Continuity of Care Plus/CoC+ Gaps &Insights)
Introducing the launch of Continuity of Care Plus (CoC+) Gaps & Insights for members identified as high utilizers or with multiple ER visits. Providers are eligible for an extra $100 for completing additional sections on the Appointment Agenda. $100 is in addition to CoC bonus for assessing and closing Risk Gaps. Please refer to your provider portal or your health plan representative.
Clinical Documentation Improvement (CDI) 2025 Webinar Series
Did you know? We offer Risk Adjustment, Coding and Documentation Education. Join us for discussions to help you optimize documentation and risk adjustment coding, Register here!
- Learn how to stay compliant with regulatory requirements
- Learn compliant coding practices and accurately capture a patient’s complexity
- Learn to identify elements to support code assignment
- …...and more!
Live risk adjustment education tailored for healthcare providers, non-physician providers, coders billers, administrative and support staff. Advanced registration is required. Utilize the corresponding registration link provided for each topic to register (links are unique to each webinar). If you have questions or need assistance with registration, email us at: CDIWebinars@centene.com.
Policy Updates
Clinical Policies
Ambetter of Tennessee has recently updated select clinical policies with some added criteria requirements that may impact the prior authorization process. Please see the revision log within each policy to review the changes. This Clinical Policy Updates page reflects upcoming clinical policy changes. Please refer to this page for recent policy updates and reach out to your Provider Relations representative if you have any questions. For a list of all active clinical policies, visit the Clinical & Payment Policies page.
The following policies had updates effective 11/1/2025:
CP.MP.37 Bariatric Surgery
CP.MP114 Disc Decompression Procedures
CP.MP.115 Discography
CP.MP.244 Liposuction for Lipedema
CP.MP.116 Lysis of Epidural Lesions
CP.MP.24 Multiple Sleep Latency Testing
CP.MP.188 Pediatric Oral Function Therapy
CP.MP.210 Repair of Nasal Valve Compromise
CP.MP.126 Sacroiliac Joint Fusion
CP.MP.182 Short Impatient Hospital Stay
Pharmacy Policies
In a continuous effort to make it easier to do business with us, Ambetter of Tennessee has added pharmacy policies to their Clinical & Payment Policies page. Please refer to this page for policy updates and review the revision log within each policy to view any policy changes.
In partnership with Evolent, the most effective way to manage your Authorization requests for Cardiology, Oncology, and MSK is through RadMD.
Welcome to RadMD.com | RADMD
Online tools Available on RadMD:
- Evolent’s Clinical Guidelines
- Frequently Asked Questions
- Quick Reference Guides
- RadMD Quick Start Guide
- Claims/Utilization Matrices
For any additional support:
- Provider Service Line
Provider and Billing Manual Navigation Tips
How to Find What You Need-Fast:
- Use the Table of Contents (Pages 2-8)
- Start here to get a high-level view of every section and its page number.
- Tip: If you’re looking for topics like claims, prior auth, or eligibility, scan this section first.
- Mark frequently used sections with sticky tabs for faster paper reference.
- Use Ctrl + F (or Command + F on Mac)
- Open the PDF in a browser of PDF viewer and press Ctrl + F.
- Type in Keywords like:
- “Clean claim”
- “Credentialing”
- “Prior authorization”
- “Member ID card”
- This is the fastest way to search the manual digitally.
- Use the Appendices (Start on p. 137)
- Includes quick references like:
- Appendix III: Common EOP Denial Codes
- Appendix V: EDI Rejection Codes
- Appendix VI: Claim Form Instructions
- Appendix VII: Billing Tips & Reminders
- Look for Section Headers
- Section headers can be found at the beginning of each section in bold.
- Flip through quickly to jump to:
- “Medical Management”
- “Provider Administration & Role of the Provider”
- “Member Benefits, Eligibility, Identification, & Cost Share”
- Bookmark Important Contacts (Page 13-14)
- Save or print the contact list for:
- Provider Services
- Claims Support
- Credentialing
- Imaging (Evolent)
- Fraud Hotline
- Save or print the contact list for:
- Save Key Sections Separately
- Download and save the PDF.
- Use digital bookmarks in your PDF viewer to label key sections.
- Use the Ambetter of Tennessee Website
- Some updated tools and forms are easier to find online:
- www.ambetteroftennessee.com
- Look under ‘For Providers’ —> Manuals, Forms, Prior Auth, etc.
- Some updated tools and forms are easier to find online:
Community Events
Ambetter of Tennessee is committed to supporting our community. Do you have an upcoming event or ideas for us to partner with you to help support our members? If so, you we would love to hear your thoughts and ideas. Please contact Trillo Shipman, Director of Community Relations.
Medicare Prior Authorization effective 10/1/2025
Wellcare requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare.
Wellcare is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at Authorization Lookup | Wellcare.
Effective October 1, 2025, the following are changes to prior authorization requirements:
| Service Category | PA Rules | Procedure Codes |
|---|---|---|
| Skin Subsitutes & Wound Dressing | PA Required | C9358, C9360, C9363, Q4111, Q4115, Q4117, Q4118, Q4125, Q4134, Q4135, Q4136, Q4139, Q4145, Q4162, Q4165, Q4166, Q4167, Q4168, Q4170, Q4171, Q4174, Q4176, Q4177, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4214, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248, Q4251, Q4252, Q4253 |
Quality Improvement
Help Close the Gap on Diabetic Eye Screenings with RetinaVue
Wellcare is committed to closing EED care gaps and driving progress toward a 4+ Star rating. With 43% of the total Star weight tied to CAHPS and HEDIS, closing diabetic eye exam gaps is critical. Currently, 1,061EED gaps remain open across our diabetic population—each representing a member at risk for retinal damage and potential vision loss.
To support early detection, Wellcare is offering RetinaVue-700 cameras on loan to provider offices. These devices allow for quick, in-office retinal screenings—especially valuable for members who may skip annual eye exams. Wellcare can also assist with closing the care gap.
How to Get Started:
- Connect with your Quality Practice Advisor (QPA) or Provider Engagement contact.
- Sign the Eye Camera Loaner Agreement.
- Schedule screenings (stand alone or during existing visits.
Let’s work together to improve outcomes—and our Star Ratings—by detecting diabetic retinal diseases early.
Risk Adjustment
Risk Adjustment - Chart Chase Season
Wellcare is currently active for our 2024 DOS Risk Adjustment Chart Chase project. The project runs from June 2025 through December 2025. Your active participation is crucial for accurate data collection and to improve quality care outcomes. We ask that you please prioritize the medical record requests which will be coming from the vendor Datavant. Here's to a successful chart chase season!
Medicare Continuity of Care (CoC) and CoC+ Programs, Centene Provider Portal Training 2025
Did you know? We offer Medicare CoC/CoC+ Centene Provider Portal Training. Join us for a Medicare-focused provider webinar covering Centene’s Continuity of Care (CoC) and CoC+ Programs. Click here to Register!
- Learn how these programs work
- Learn how to access and use the tools available using the Centene Provider Portal (Provider Analytics)
- Learn how you can support accurate documentation and continuity of care for your patients.
Who should attend?
- Providers and Clinicians
- Risk Adjustment Coordinators
- Billing/Coding Staff
- Office Managers
- Any team member using the Centene’s Provider Portal for Medicare Risk Adjustment
These sessions are designed to help your team get the most out of the CoC and CoC+ programs. Click here to Register!
Availity Editing Services
In a continuous effort to make it easier to do business with us, Ambetter of Tennessee has introduced Availity Editing Services (AES). Centene has partnered with Availity to return rejection messages on its behalf via AES messages.
AES can identify a claim error upfront and return a message to you for correction before sending the claim on to the plan to be adjudicated. You should review edit messages for potential corrections to the suggested claim line(s). If you make updates to the claim, this may help the claim process correctly the first time, preventing errors, improving payment accuracy, and claims adjudication turnaround time. If, after reviewing the message, you find it does not apply, please resubmit the claim as-is and this will allow a bypass of the edit in cases where it may not be applicable. This is not intended as a new method to deny a claim, nor does it bypass or replace downstream edits.
If you submit claims via Availity, learn how to gather your reporting by joining one of Availity’s free webinars to learn additional tips for streamlining your workflow:
If you need assistance with registering for Availity Essentials, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. For general questions, please reach out to your Provider Engagement Representative or contact us at ProviderRelationsTN@Centene.com.
In partnership with Evolent, the most effective way to manage your Authorization requests for Cardiology, Oncology, and MSK is through RadMD.
Welcome to RadMD.com | RADMD
Online tools Available on RadMD:
- Evolent’s Clinical Guidelines
- Frequently Asked Questions
- Quick Reference Guides
- RadMD Quick Start Guide
- Claims/Utilization Matrices
For any additional support:
- Provider Service Line
REMINDERS
- Learning Opportunities: Provider Information Sessions are offered monthly on every 3rd Friday at 1 PM CT/2 PM ET.
- Remember to submit any demographic updates to Provider Engagement - click for document.
- Do you have any suggestions for our newsletter? Email Amber Neal.